Abstract Background The recently published SENIOR-RITA trial demonstrated that an invasive strategy did not significantly reduce the risk of adverse outcomes in elderly patients with non-ST-segment elevation myocardial infarction compared to a conservative approach. However, in the field of out-of-hospital cardiac arrest (OHCA), the optimal invasive coronary angiography (ICA) strategy in elderly patients without ST-segment elevations after resuscitation remains uncertain. Objectives To evaluate the impact of early versus delayed/no ICA on 30-day mortality across different age groups. Methods A post hoc analysis of the TOMAHAWK trial - a large, multicentre, randomised controlled trial comparing early versus delayed/no ICA in successfully resuscitated OHCA patients without ST-segment elevations - was conducted. Patients were stratified into three age groups: ≤50 years, 50–75 years and 75 years. Kaplan-Meier survival analyses were performed. Results A total of 529 patients were included: 48 patients (≤50 years), 300 (50–75 years) and 181 (75 years). Compared to younger patients, elderly patients exhibited a higher prevalence of comorbidities, including diabetes (41% vs. 7%), dyslipidaemia (47% vs. 7%), known coronary artery disease (50% vs. 12%), prior coronary artery bypass grafting (16% vs. 0%), peripheral artery disease (13% vs. 2%) and prior heart failure (31% vs. 9%). Additionally, elderly patients demonstrated poorer cardiac arrest characteristics, with lower rates of bystander CPR (51% vs. 67%), a lower incidence of shockable rhythms (45% vs. 72%) and lower arterial pH (7.21 vs. 7.26). At ICU admission, they presented with lower left ventricular ejection fraction (40% vs. 45%) and higher SAPS II scores (73 vs. 56). Elderly patients more frequently received ICA via femoral access (75% vs. 58%) and exhibited more complex coronary artery disease, including a higher prevalence of three-vessel disease (49% vs. 13%). The 30-day mortality and neurological impairment rates were age-dependent, with mortality rates of 32% (≤50 years), 45% (50-75 years) and 69% (75 years) (Figure), and neurological impairment rates of 18%, 34% and 37% at 30 days, respectively. Among elderly patients, immediate ICA was associated with higher 30-day mortality compared to delayed/no ICA (p log-rank=0.048; Figure). Conclusions Elderly patients with successfully resuscitated OHCA had a higher burden of comorbidities, worse cardiac arrest parameters, higher degree of critical illness at ICU admission and more complex coronary disease. Early ICA was associated with increased mortality in this patient group, suggesting that an early invasive strategy might be carefully reconsidered in critically ill elderly patients.
Thevathasan et al. (Sat,) studied this question.